Is fusion the most suitable treatment option for recurrent lumbar disc herniation? A systematic review.

OBJECTIVE: Recurrent lumbar disc herniation (rLDH) is a common issue after primary discectomy and can cause severe pain, morbidity, and reoperation. The purpose of this systematic review was to evaluate the surgical management of recurrent lumbar disc herniation. METHODS: A systematic literature search was conducted using Pubmed and Embase databases on 18thAugust, 2019. The inclusion and exclusion criteria were applied according to study design, surgical approach, language, number of patients; and spinal level. Data extracted included patient demographics, and clinical outcomes (patients with excellent/good outcomes; VAS back and leg score improvement, complication and recurrence rates). RESULTS: Sixteen studies, (comprising of seven prospective and nine retrospective) met the inclusion criteria. Ten studies evaluated discectomy only; four analysed fusion, and two analysed both discectomy only and fusion approaches. Fusion approaches recorded a superior success rate (8.3 % higher, p>0.05); postoperative VAS back score improvement (5 % higher, p>0.05) than discectomy alone.  However, discectomy alone approaches recorded a more favourable postoperative VAS leg score improvement (4.2 % higher p>0.05), and complication rate (3.2% lower, p>0.05) than fusion techniques. CONCLUSION: There is significant heterogeneity in clinical outcomes reported for studies after surgical intervention in rLDH patients. Neither discectomy nor fusion's superiority was statistically significant. Despite fusion yielding longer operative times, and length of stay (adding to the expense), it is superior in minimising mechanical instability and recurrence. Finally, we conclude that both approaches are equally efficacious in rLDH cases, and choice should be based on a case by case basis.